(P150) A POST-ARREST CARE BUNDLE IMPROVES QUALITY OF CARE AND CLINICAL OUTCOMES DURING THE NORMOTHERMIA ERA

Background: Care bundles have demonstrated improved survival and functional recovery in patients with cardiac arrest who achieve return of spontaneous circulation (ROSC). Canadian literature has supported a post-ROSC bundle that includes targeted temperature management (TTM), coronary angiography, and routine critical care management. TTM targets have shifted, given new evidence suggesting equipoise between hypothermia (temperature target 33°C) and normothermia (temperature target < 37.5°C). Changes in temperature targets, such as from 33°C to 36°C, have been associated with significantly higher fever rates, poorer compliance, and increased mortality. Our centre transitioned to ‘ad hoc’ normothermia in August 2021. In attempt to improve compliance with temperature targets, we developed a new normothermia post-ROSC bundle.

METHODS AND RESULTS: In August 2021, intensivist-driven ‘ad hoc’ normothermia was initiated. Temperature targets, temperature duration, sedation, and cooling mechanism were at the discretion of the attending intensivist. In December 2021, a post-ROSC normothermia protocol was created emphasizing a step-wise approach to fever prevention for 72 hours (temperature target < 37.5°C). This protocol was refined through two rapid plan-do-study-act (PDSA) cycles. Patients with temperatures < 37°C received no cooling therapy. Patients with temperatures >37°C received cold saline, ambient cooling devices, ice packs and finally paralysis. All patients in the normothermia ‘protocol’ received high dose sedation for 40 hours. Sedation between hours 40-72 was at the discretion of the attending intensivist. We conducted a retrospective cohort study of patients in the ‘ad hoc’ and ‘protocol’ groups between August 1, 2021 and April 1, 2022 in two tertiary academic adult ICUs. Over the 8 month period, 58 post-ROSC patients were admitted; 24 in the ‘ad hoc’ and 34 in the ‘protocol’ groups. Patient demographics were similar between groups, although the ‘ad hoc’ group had more shockable rhythms (67% vs 24%, P=0.001) and more cardiac catheterizations (42% vs 15%, P=0.02). Patients in the ‘protocol’ group were significantly less likely to have a fever at 40 hours (6% vs 40%, P=0.0009) and 72 hours (14% vs 65%, P=0.00005) compared to those treated with ‘ad hoc’ normothermia. In addition, patients in the normothermia ‘protocol’ used significantly less paralytics to maintain target temperature (24% vs 50%, P=0.03). The normothermia ‘protocol’ resulted in similar mortality (56% vs 58%, P=0.85).

Conclusion: Use of a normothermia ‘protocol’ in post-ROSC patients resulted in fewer fevers and less paralytic use compared to ‘ad hoc’ temperature management. Institutions desiring change to post-ROSC normothermia should consider adopting a protocolized approach for improved quality of care.